Psychiatric emergencies

Question 1

What is neuroleptic malignant syndrome? What is the pathophysiology (briefly)?

Answer 1

A life threatening disorder caused by anti-psychotics.

Caused by decreased levels of dopamine activity. Due to the anti-psychotic drug blocking dopamine receptors and a reduced functioning in the dopamine receptor due to genetics.

Question 2

Clinical features of neuroleptic malignant syndrome?

Answer 2

CANCAN

Cognitive: confusion, disorientation
Autonomic: hyperpyrexia, sweating, tachy
Neuro: seizures, coma, stiffness (lead pipe)
Cardiac: long QT
Acidosis: raised CK
Neutrophils: leukocytosis

Question 3

What would you see in blood tests of someone with neuroleptic malignant syndrome?

Answer 3

Raised creatinine kinase

Question 4

Management of neuroleptic malignant syndrome?

Answer 4

Stop the anti-psychotic drug
Supportive treatment, reduce temp, fluids, ITU
Treat rhabdomyolysis (fluids, diuretics)

Question 5

Is neuroleptic malignant syndrome more often caused by typical or atypical anti-psychotics?

Answer 5

Typical

Question 6

Risk factors for neuroleptic malignant syndrome?

Answer 6

Anti-psychotic drugs used in the following ways:

• At high-potencies
• A rapid increase in the dosage
• Long-acting forms of neuroleptics

Patients with Lewy body dementia
Genetic predisposition

Question 7

List some psychiatric emergencies.

Answer 7

Neuroleptic malignant syndrome

Patient at risk of self-harm or harming others

Intoxication

Delirium tremens

Question 8

How would you manage a violent patient using non-pharmacological methods?

Answer 8

Ensure your own safety

Try to de-escalate by talking, using body language, listening

Use minimum force possible

Resort to rapid tranquilisation if need be

Question 9

You need to rapidly tranquilise a violent patient, how would you do this?

Answer 9

1. Oral lorazepam 1-2mg
2. Repeat after 45 mins
3. IM Options:
   - Lorazepam 1-2mg
   - Promethazine 50mg
   - Olanzapine 10mg
   - Haloperidol 5mg (as a last resort)